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Confirmation of brainstem death in the UK tends to be undertaken by intensive care physicians. It is, therefore, a process unfamiliar to many general neurologists. If neurologists are called upon, it is often to provide input on difficult cases such as patients with residual reflex movements, patients in whom usual examinations are invalid or patients who require ancillary tests. In these circumstances, a working knowledge of the brainstem testing process is essential, together with an awareness of the potential pitfalls.
This review summarises the key components of brainstem testing and provides practical advice when dealing with these patients. It primarily focuses on clinical practice in the UK but includes a comparison with other countries in Europe and the rest of the world.
Testing for brainstem death in the UK
Definition of brainstem death
A person is dead when they have irreversibly lost the capacity for consciousness and breathing. This implies loss of brainstem function. In patients who have suffered cardiopulmonary arrest (including failed resuscitation), loss of brainstem function occurs as a consequence of catastrophic brain injury. In these patients, death is diagnosed after confirming simultaneous onset of apnoea and unconsciousness, the absence of circulation for a minimum of 5 min (central pulse on palpation and heart sounds on auscultation) and the absence of neurological reflexes (pupillary responses, corneal reflex and motor response to supraorbital pressure).1 Any contributing causes for the arrest should have been reversed.
Irreversible brainstem damage also occurs in patients with other causes of coma. In these patients, death has occurred and the heart will inevitably stop beating (although the time over which this occurs may vary considerably). The appropriate course of action is therefore to consider withdrawal of mechanical ventilation—the ethical justification for which has now passed—and allow the heart to stop.
In patients with coma, testing brainstem reflexes is used as a proxy for brainstem function, while …
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